VICTIM COMPENSATION FUND APPLICATION The Crime Victim Compensation Program operates pursuant to C.R.S et seq.

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1 CRIME VICTIM COMPENSATION BOARD Fourth Judicial District El Paso and Teller Counties 105 E Vermijo, Suite 111 Colorado Springs, CO Phone (719) Fax (719) VICTIM COMPENSATION FUND APPLICATION The Crime Victim Compensation Program operates pursuant to C.R.S et seq. ELIGIBILITY REQUIREMENTS *: 1. The crime must be one in which the victim sustains mental or bodily injury, dies or suffers property damage to residential exterior locks, windows or doors as a result of a compensable crime. 2. The victim must fully cooperate with law enforcement officials (law enforcement, district attorney, etc.) 3. The crime must be reported to a law enforcement agency within 72 hours of occurrence. 4. The injury or death of the victim was not the result of the victim s own wrongdoing or substantial provocation. 5. The victimization occurred on or after July 1, The application for compensation must be submitted within one year from the date of the crime and within six months for residential property damage claims. 7. The crime occurred in El Paso or Teller County; or, in another state or country and the victim is a resident of El Paso or Teller County. * The Crime Victim Compensation Board may waive some of the above listed requirements for good cause or in the interest of justice. GENERAL INFORMATION: 1. An arrest does not have to be made in order for a victim to become eligible to apply to the Compensation Program. 2. Compensation may be requested for medical expenses, mental health counseling, medically necessary devices (dentures, eyeglasses, hearing aids, and prostheses), loss of earnings due to injury, outpatient care, home health services, funeral expenses, exterior residential doors/locks/windows, and loss of support to dependents in the event of death. Requests must be directly related to the crime reported to the law enforcement agency. 3. Compensation for property damage may be awarded for the cost of replacement or repair to exterior residential doors, locks, other locks, and windows that are damaged during the commission of a crime. Claimant must supply a bill or estimate. 4. By law, you must apply for all other sources of financial assistance or reimbursement, including private insurance, Medicaid and Medicare. 5. Please attach all itemized bills, receipts and estimates directly related to the crime. You may apply if you have not received any bills as of this date, forwarding bills as you receive them. 6. Your claim will be verified and presented to the Victim Compensation Board, a three-member panel of volunteers appointed by the elected District Attorney. This process may take up to 60 days from the receipt of all required documentation necessary to present a claim request to the Board. 7. Compensation for an entire claim may not exceed the statutory limit of $30,000. Compensation for individual categories is limited by Board policy; please call if you have questions about specific category limits. 8. Should your request be denied, you have a right to request reconsideration of the Board s decision and have the right to submit new or additional information, which relates to the reason(s) for the Board s denial or reduction or your claim. You may arrange for reconsideration by contacting the Victim Compensation program within 60 days of the date in which you receive notice of the denial or reduction of your claim. You may appear in person, or by written letter to the Board. In the event the Board upholds the denial, you have a right to have the Board s decision reviewed in accordance with the Colorado Rules of Civil Procedure within 30 days. Your application and information contained in your file may be subject to discovery in court proceedings.

2 CRIME VICTIM COMPENSATION APPLICATION FORM INSTRUCTIONS Pursuant to statute (2)(a), the applicant must provide the Compensation Program with any pertinent requested information to process this application. Incomplete applications will be returned or delayed until all information is received. SECTION I VICTIM INFORMATION: The name of the person who was injured or killed is considered the primary victim. A secondary victim is someone with a close, familial type relationship with the victim or someone who is a witness to the crime. A separate application is required for each family member applying. It is very important that you provide a complete mailing address, including city, state and zip code so that we can continue to keep you notified of the status of your application. A telephone number and/or address allows us to contact you with any questions. Your Social Security number may be requested only to verify bills submitted for payment. SECTION 2 CLAIMANT INFORMATION: This is the person who will be contacted regarding this claim. It may be the same person as the primary victim or it may be a legal guardian or family member of the primary victim. Please note the relationship to the victim and provide a telephone number or address for contact. SECTION 3 CRIME INFORMATION: The majority of this information will be obtained from a copy of the offense report taken by the investigating law enforcement agency. You DO NOT need to provide a copy of this report. Completing this entire section, to the best of your knowledge, helps us make sure that we have the right offense report related to your application. SECTION 4 INSURANCE AND OTHER COLLATERAL SOURCE INFORMATION: By federal and state statute, Crime Victim Compensation is the payer of last resort. If you have available any other sources of payment for the bills you are submitting, you must disclose this information. Incomplete applications will not be able to be processed. SECTION 5 REQUEST FOR SERVICES: This section has nine subsections. Mark the services you are requesting assistance with or that you anticipate needing assistance. Write (N/A) not applicable, if you are not requesting assistance for that subsection. Mental Health Counseling: For Primary and Secondary victims. Secondary victims are persons that have a close, familial type relationship with the primary victim or someone who is a witness to the crime. The Board will only approve therapy with state licensed therapists (Paid at $100 per session/$50 group) or licensure candidates (paid half the rate.) (New rate effective 4/4/18) Alternatives to Mental Health: With a proper referral you may apply for self-defense and/or massage therapy. Medical: All bills submitted must be directly related to the crime and are ultimately your responsibility. Crime related bills or estimates can be forwarded to the Compensation Program as you receive them. All bills and insurance correspondence received will be verified to confirm date, type and cost of service before a payment determination can be made. (Paid at 100% effective 10/1/2016) Personal Medical Items: This refers to any medically necessary device that was stolen or damaged as a result of the criminal incident. This may be hearing aids, glasses, dentures, etc. Send crime related bills or estimates. Loss of Earnings: 1-month max benefits for mental health reasons or 2 months max for physical health reasons. You may request loss of earnings only if you missed work because of your physical or emotional injuries related to the crime and you did not have paid vacation or sick leave provided by your employer. You must provide a doctor s note, a recent pay stub, and your employer must verify the unpaid time you had to miss from work on a form provided by the Compensation Program. If you are self-employed, you must submit a copy of your last year s tax return. Loss of Support to Dependents (Non-DV): If the primary victim has died as a result of a crime, persons who were wholly or partially dependent upon the primary victim s income or whose income will now be decreased or lost because of the primary victim s death can request loss of support. This may include court ordered child support. Loss of Support to Dependents (DV & Sexual Assault on Child): If certain criteria are met, loss of support can be awarded in cases where the victim was living with and financially dependent upon the offender. Loss of support requests must be submitted within 10 days of the offender being legally removed from the home. Please contact the Victim Compensation office for more information. Residential Property: Please note if you have a homeowner s insurance deductible; please list the deductible amount. If you do not have homeowner s insurance, please write N/A in the space provided. ($1000 or deductible maximum) Funeral Expenses: If you have paid for funeral expenses or if the bills remain outstanding, please submit all bills or receipts that you wish to be considered for payment or reimbursement. The person who paid for the funeral is the person eligible to receive reimbursement if approved. Please note: There is a $9000 per decedent maximum for funeral / burial expenses. Emergency Request: ER requests must be received no later than 14 days from the crime date. Please speak with the Coordinator or the Program Assistant for more information regarding emergency assistance and eligibility. SECTION 6 CIVIL LAWSUIT: By signing the application, you agree to repay any funds you receive in a civil lawsuit for expenses paid by the Compensation Program. SECTION 7 RELEASE OF INFORMATION & VICTIM RIGHTS AND RESPONSIBILITIES: Your initials by each section, as well as your signature and the date are necessary to complete the application and to authorize the Compensation Program to verify bills on your behalf. *Incomplete applications or Applications without signatures may be returned to you and will delay payment.

3 SECTION 1 VICTIM INFORMATION PLEASE PRINT Return application and crime related bills to: Victim Compensation Program Primary Victim Secondary Victim 105 E. Vermijo Ave., Suite #111 Colorado Springs, CO Fax: The name of the person who was injured or killed is considered the primary victim. A secondary victim is someone with a close, familial type relationship with the victim or someone who is a witness to the crime. Victim Name (First, Middle, Last) Mailing Address City State Zip Code County of Residency State of Permanent Residency Work Phone Home Phone Other Phone Birth Date Age at time of crime Gender: Male Female Marital Status: Married Single Separated Divorced Widowed The following information is used for statistical purposes only. This information is needed to comply with Federal regulations. Disabled: Race: Referral Source: Yes American Indian or Alaska Native Police Agency Victim Advocate No Asian District Attorney Victim Advocate Mentally Black or African American District Attorney s Office Physically Hispanic or Latino Social Services Native Hawaiian or other Pacific Islander Hospital Did the crime White Non-Latino or Caucasian Therapist cause your disability? Some Other Race Other Yes Multiple Races No SECTION 2 CLAIMANT INFORMATION SAME AS ABOVE (only if crime victim is claimant) Complete only if person submitting application is not the victim, i.e.: victim s parent or guardian or relative of victim. Claimant s Name (Parent/Guardian/Relative) Mailing Address Home Telephone Cell Telephone /Work Telephone City/State/Zip Date of Birth Relationship to Victim *Incomplete Applications submitted or Applications without signatures will be returned

4 SECTION 3 CRIME INFORMATION Type of Crime: (check all that apply) Assault Burglary/Criminal Mischief Careless Driving Resulting in Injury or Death Child Physical Abuse Child Sexual Assault-Family Member Child Sexual Assault-Non-Family Member Domestic Violence Drunk Driver / Vehicular Assault / Vehicular Homicide Hit and Run Resulting in Injury or Death Murder/Homicide Attempted Murder/Homicide Sexual Assault-Adult Victim Other: 1. DATE OF CRIME: 2. DATE CRIME REPORTED 3. POLICE DEPARTMENT/AGENCY CRIME REPORTED TO: 4. POLICE OFFICER ASSIGNED: 5. POLICE REPORT NUMBER: 6. WHO COMMITTED THE CRIME? 7. RELATIONSHIP TO VICTIM: 8. HAS THE OFFENDER BEEN CHARGED IN COURT? YES NO UNKNOWN 10. DID THE CRIME OCCUR AT WORK: YES NO 9. DISTRICT ATTORNEY S OFFICE CASE NUMBER: 11. COUNTY WHERE CRIME OCCURRED: SECTION 4 INSURANCE/OTHER COLLATERAL SOURCE INFORMATION You are required to submit all bills to your insurance carrier or other collateral source related to your request for assistance; check all sources of alternate payment for bills submitted to the Compensation Program. Please indicate if the following applies to you and your claim request: Do you have health insurance coverage: Yes No If yes, please provide the Policy #: Group # Company name and address: Do you have auto insurance: Yes No Do you have Homeowner s/renters: Yes No Deductible for Homeowner/Renter s Insurance $ Disability Insurance: Yes No If yes to any of these, please read and complete the following: Private Insurance: Yes No Medicaid: Yes No Group Insurance: Yes No Medicare: Yes No Department of Social Services: Yes No Worker s Comp: Yes No CHP / CHP+: Yes No Military Coverage: Yes No Colorado Indigent Care Program: Yes No Other: Yes No SECTION 5 REQUEST FOR SERVICES (Please check all boxes that apply) MENTAL HEALTH COUNSELING Are you (victim) currently seeing a therapist related to this crime? Yes No If yes, please list the name and phone number of the therapist below. Therapist Name SECTION 5 CONTINUED REQUEST FOR SERVICES Telephone Number (The Board will only approve therapy with state licensed therapists.) Do you require a language interpreter? Yes No ALTERNATIVES TO MENTAL HEALTH COUNSELING (only for Primary Victims) Massage therapy Requires a referral from treating physician or mental health therapist ($1,500 max) Self defense course Requires a referral from treating physician or mental health therapist ($1,500 max) *Incomplete Applications submitted or Applications without signatures will be returned

5 MEDICAL: Submit copies of crime related itemized bills as you receive them. Hospital: Yes No Physician: Yes No Dental: Yes No Physical Therapy: Yes No Requires a referral from treating physician Chiropractic: Yes No (Maximum - $1,500) Home Nursing Care: Yes No (must be provided by a Certified Home Care Health Agency) (Maximum - $7,000 per family) Acupuncture: Yes No (Maximum - $1,000 per family) Interpreter Services: Yes No Other: NOTE: If plastic surgery, reconstructive surgery, major dental work, ongoing physical therapy, etc., are being recommended, your provider must complete a treatment plan that explains how the injuries and treatment relate to the crime and an estimate of total cost for the procedure. The Victim Compensation Board will review your request and you will be informed as to whether or not we will be able to assist with the cost. If possible, please list service providers noting if the bill is paid or outstanding. You may add additional sheets if needed. Service Provider Paid Outstanding Estimate Service Provider Paid Outstanding Estimate Service Provider Paid Outstanding Estimate PERSONAL MEDICAL ITEMS Submit copies of crime related itemized bills or estimates Was the item stolen, damaged or destroyed during the criminal incident? Yes No Eyeglasses/Contact Lenses: Yes No (Max - $600) Dentures: Yes No Hearing Aid: Yes No Prosthetic Device: Yes No Medication: Yes No Other: LOSS OF EARNINGS DUE TO PRIMARY VICTIM S INJURY ONLY Loss of earnings is not applicable for lost wages due to reporting the crime, testifying in court, interviews with police/da, etc. To qualify for lost wages, you have to have been employed at the time of the incident. Was the victim able to use any of the following types of leave due to physical or emotional injury caused by the crime? Sick Leave: Yes No Vacation Leave: Yes No Personal Leave: Yes No FMLA: Yes No If you are self-employed you must furnish a copy of the past year s tax return so we can accurately determine lost wages. A Claim for Lost Wages form is included for you to give to your employer to verify your rate of pay and that the unpaid time from work that is directly related to this criminal incident. You will be asked to include a copy of a recent pay stub and if you are requesting more than a week of lost wages, a note from your doctor or therapist. LOSS OF SUPPORT TO DEPENDENTS / NON-DV (up to 85% gross wage for 8 weeks, Maximum - $6,500 per family) Persons who were wholly or partially dependent upon the victim s income at the time of death or whose income has been severely lessened or lost because of this criminal incident may be eligible for compensation up to 85% of the gross wage of the victim for a maximum of 8 consecutive 40-hr. work weeks, not to exceed $6,500 per family. Please include a copy of the dependent s birth certificate, proof of permanent guardianship and/or copy of marriage license, and proof of income of deceased at the time of death. 1) Dependent s name 2) Date of Birth 3) Relationship to Victim LOSS OF SUPPORT TO DEPENDENTS / SAC OR DV (up to 85% gross wage for 8 weeks, Maximum - $6,500 per family) In certain cases, and if certain criteria are met, victims who were wholly or primarily dependent upon the offender s income before the offender was legally removed from the home due to the crime incident may be eligible for compensation. Please call for more information. Additional documentation will be required by the Crime Victim s Compensation Board to support your request. Request must be submitted within 10 days of the offender being legally removed from home. Awards may be applied to specific household expenses only. RESIDENTIAL PROPERTY (Damaged or destroyed during the crime / Maximum up to deductible amount) Exterior Doors: Yes No Exterior Windows: Yes No Other Locks: Yes No Re-key Exterior Locks: Yes No Crime Scene Cleanup: Yes No Insurance Deductible Amount: $ Security System Request: Yes No (Must be a homeowner /Based on specific crimes / Maximum - $1,000 or up to deductible amount) FUNERAL EXPENSES: Submit copies of itemized bills, if available. ($9,000 maximum for funeral / burial.) Have funeral expenses been paid? Yes No Name of person who paid for funeral expenses Funeral Service Provider and Telephone Number Telephone Number EMERGENCY REQUEST: The Victim Compensation Program may be able to assist with some emergency requests if it is determined undue hardship would result to the applicant if payment were not made in 72 hours. *Incomplete Applications submitted or Applications without signatures will be returned.

6 SECTION 6 CIVIL SUIT CIVIL LAWSUIT: Are you planning to sue the person(s) or business responsible for this injury? Yes No SECTION 7 EMERGENCY REQUEST If yes, please note that you must notify the Compensation Board with written evidence of the amount and terms of settlement. SECTION 7 RELEASE OF INFORMATION / RIGHTS & RESPONSIBILITIES Initial Each Box Below PLEASE READ CAREFULLY, INITIAL EACH SECTION, SIGN AND DATE CERTIFICATE OF APPLICATION: The information contained in this application for Crime Victim Compensation is true and correct to the best of my knowledge. I understand that untruthful statements provided or falsified documentation submitted may result in a denial of my claim and is punishable by law. CLAIMANT RESPONSIBILITY: I understand that I am responsible for my bills relating to this crime and have the burden of providing any documentation to the Crime Victim Compensation Board to assist with verification of my claim. I must also notify service providers of my application to the Crime Victim Compensation Program. COOPERATION: I understand that my failure to cooperate with law enforcement (police, sheriff, prosecutor, etc) may result in the denial of my claim. In addition, I am further aware that if I fail to cooperate with the prosecution of the case from which my losses were sustained, I will be ineligible for any further compensation and will be fully liable to reimburse the Crime Victim Compensation Program for any and all compensation awards received. SUBROGATION AGREEMENT: I hereby agree to notify the Crime Victim Compensation Program in the event that benefits become available to me, including but not limited to a civil lawsuit action, in payment of the same expenses for which I receive from the Crime Victim Compensation Program. I further agree to retain so much of the recovered funds as necessary to reimburse the Compensation Program to the extent of the compensation I received from the Program. ALTERNATIVE APPLICATION PROCESS: If you feel the Victim Compensation Board in the Fourth Judicial District is unable to impartially review your claim due to personal or professional relationship(s) with two or more Board members, it will be sent to another district for review once the conflict has been declared by the Board. The Fourth Judicial District must receive a request for alternative review in writing. If your claim is approved, bills will be paid from the Fourth Judicial District. I understand this may delay the processing of my claim. REPAYMENT OF CRIME VICTIM COMPENSATION: I hereby agree to repay the Crime Victim Compensation Fund if payments are received from the offender (restitution or civil action), insurance, or any other government or private agency as compensation for this injury or death after receipt of payment from the Crime Victim Compensation fund. RIGHT TO RECONSIDERATION: Should my claim for compensation be denied, I would be notified of the reason in writing. I understand that I have the right to request reconsideration by the Crime Victim Compensation Board and may do this by submitting a letter within 60 days which addresses the reason for the denial as stated in the letter. You must then appear in person at the next scheduled Board meeting to present your case. I understand that the burden of proof is upon me as the applicant to show the claim is reasonable and compensable under the Colorado Crime Victim Compensation Act. In the event the denial is upheld by the Board following the reconsideration, I understand that I may have the Board s decision reviewed in accordance with the Colorado Rules of Civil Procedures by a district court. RELEASE OF FUNDS: I hereby authorize release of funds awarded to me under the Colorado Crime Victim Compensation Act to be paid directly to the service provider(s)/out of pocket claimant as applicable to my claim. I understand that any claim request approval is subject to the availability of funds and the discretion of the Board. RELEASE OF INFORMATION AUTHORIZATION: I hereby authorize the release of all information from any employer, physician, hospital, Department of Social Services, civil attorney, medical and/or mental health service providers and/or any other creditor or agency for the purpose of verifying the claims that I have submitted to establish validity of a claim. I further understand that any information provided may be subject to disclosure under the law. This authorization may be revoked at any time in writing, except to the extent that action has already been taken in reliance upon it. My signature authorizes release of all such information as specified above. A photocopy or exact reproduction of this signed release shall have the same effect as the original. Signature of Victim/Claimant Date Printed Name of Victim/Claimant Revised 1/25/19 *Incomplete Applications submitted or Applications without signatures will be returned.

7 VICTIM COMPENSATION PROGRAM Fourth Judicial District 105 E. Vermijo, Suite #111 Colorado Springs, CO (719) Fax: (719) Please print LOSS OF WAGES VICTIM'S NAME: THE PROGRAM WILL ONLY COMPENSATE THE VICTIM FOR WAGES LOST DUE TO PHYSICAL OR EMOTIONAL INJURIES DIRECTLY CAUSED BY THE CRIME. LOST WAGES WILL NOT BE PAID FOR TIME LOST DUE TO COURT APPEARANCES, APPOINTMENTS WITH CRIMINAL JUSTICE PERSONNEL OR APPOINTMENTS WITH SERVICE PROVIDERS. IF YOU ARE REQUESTING LOSS OF WAGES, TAKE THIS FORM TO YOUR EMPLOYER AND HAVE IT COMPLETED AND SIGNED BY YOUR SUPERVISOR/EMPLOYER EACH MONTH. IF YOU ARE SELF-EMPLOYED YOU MUST SUBMIT COPIES OF YOUR TAX RETURNS. IF CLAIMING LOST WAGES, YOU MUST SUPPLY THE FOLLOWING DOCUMENTATION: 1) THIS FORM MUST BE COMPLETED AND RETURNED BEFORE YOUR REQUEST FOR LOST WAGES CAN BE PROCESSED. 2) A LETTER FROM YOUR TREATING PHYSICIAN OR THERAPIST INDICATING YOUR INABILITY TO WORK DUE TO INJURIES SUSTAINED AS A RESULT OF THE CRIME AND INDICATING LENGTH OF TIME OF INABILITY TO WORK. ANY REQUEST OVER 5 DAYS OF LOST WAGES REQUIRES A DOCTOR S NOTE. 3) IF REQUESTING LOST WAGES FOR MORE THAN MORE MONTH YOU MUST TAKE THIS FORM TO YOUR EMPLOYER EACH MONTH FOR VERIFICATION EMPLOYEE'S NAME: JOB TITLE: WAS THIS PERSON EMPLOYED ON THE DATE OF INJURY? YES NO First day of missed work: Last day of missed work: WAS THIS PERSON INJURED WHILE AT WORK? YES NO WAS SICK LEAVE / ANNUAL LEAVE / FMLA OR DISABILITY PAID? YES NO HAS THIS PERSON RETURNED TO WORK? YES NO IF YES, WAS WORKERS COMP PAID YES NO IF YES, THROUGH WHAT PERIOD FROM: TO: IF YES, DATE RETURNED? / / IF YES, THROUGH WHAT PERIOD FROM: TO: HOURS WORKED PER DAY HOURS WORKED PER WEEK HOURS WORKED PER MONTH NUMBER OF DAYS MISSED RATE OF PAY HOURLY WEEKLY COMMISSION $ MONTHLY DAILY OTHER TOTAL AMOUNT OF LOSS OF WAGES: $ EMPLOYER'S (FIRM) NAME: ADDRESS: EMPLOYER (SUPERVISOR/REPRESENTATIVE) NAME: JOB TITLE: CITY, STATE, ZIP: PHONE NUMBER: EMPLOYER (SUPERVISOR/REPRESENTATIVE) SIGNATURE: I certify that I have read and agree to all of the information provided on the Loss of Wages Form above. Furthermore, I am aware that the information provided on the above Loss of Wages Form is true and correct to the best of my knowledge. I understand that untruthful statements will disallow my eligibility for any and all further benefits from the Crime Victim Compensation Fund. EMPLOYEE (VICTIM) SIGNATURE: DATE: *Incomplete Applications submitted or Applications without signatures will be returned. Revised: 1/25/19

8 Return application and crime related bills to: Victim Compensation Program LOST SUPPORT REQUEST 105 E. Vermijo Ave., Suite #111 4 TH JUDICIAL DISTRICT Colorado Springs, CO Fax: CRIME VICTIM COMPENSATION PROGRAM Victim Name: Suspect/Defendant Name: Were you and the suspect/defendant living in the same residence when the crime occurred? Yes No Are you and the suspect/defendant still living together? Yes No Are there any immediate plans for reunification between you and the offender? Yes No Was the suspect/defendant legally employed or receiving benefits through a benefits program (ex. Workman s Compensation, Disability, etc.) at the time the crime occurred? Yes No Please provide documentation for the two prior months from the date of the application. Suspect s Employer Contact Information: Company Name: Address: Phone Number: Supervisor: The suspect/defendant was providing: Total Support Partial Support No Support when the crime occurred. Did you and the suspect/defendant have any other sources of income besides salaries? Yes No If "yes", please list: Is the suspect/defendant providing financial support to you now? Yes No If you are awarded compensation for lost support, will the offender benefit from or have access to it?: Yes No If "yes", please explain: Please provide proof of the following information: Copies of the offender s paystubs (two months) dated up to the date of incident / or the suspect s most recent income tax return if selfemployed / or proof of direct deposits. If you do not have access to financial documents, please inform the Board in writing of your situation. Lease agreement for primary shared residence & proof of protection order (mandatory, temporary or permanent) Utility bill(s), internet service bill (cable excluded), phone bill (if primary source of communication), other household expense receipts or invoices Proof of application and eligibility status for governmental assistance (TANF, Food Stamps, LEAP, etc.) Please fill in each box below related to household expenses: $ Amount: Suspect/Defendant Paid (List $ Amount): Rent/Mortgage for primary residence: You Paid (List $ Amount): Utilities: Internet (cable excluded): Phone (if primary source of communication): Food: Other household necessities (Please list): TOTAL: * Please note, if the Crime Victim s Compensation Board grants an award- no monies will be distributed without documentation supporting the amounts. Depending on the bills paid- some bills will be paid directly to the provider and some will be categorized as reimbursable expenses. I certify that I have read and agree to all of the statements and conditions on the Crime Victim Compensation Fund Application; furthermore, I am aware that all of the information provided in this Request for Lost Support form is subject to those conditions. I certify that the information contained in this Request for Lost support is true and correct to the best of my knowledge, and I understand that any untruthful statements will disallow my eligibility for any and all further benefits from the Crime Victim Compensation Fund. Signature: Printed Name: Date: *Incomplete Applications submitted or Applications without signatures will be returned. Revised: 1/25/19